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Cluster Headaches

By Stephen D. Silberstein, MD, Professor of Neurology and Director, Headache Center, Sidney Kimmel Medical College at Thomas Jefferson University

A cluster headache causes severe pain that is felt at the temple or around the eye on one side of the head and that lasts a relatively short time (usually 30 minutes to 1 hour). Headaches usually occur regularly during a 1- to 3-month period, followed by a headache-free period of months to years.

  • Excruciating pain occurs on one side of the head, causing the nostril and the eye on that side to water.

  • People are often restless and pace.

  • Doctors base the diagnosis on symptoms.

  • Oxygen (given by a face mask) or drugs are needed to treat headaches.

  • Most people with cluster headaches need to take drugs to prevent attacks from recurring.

Cluster headaches are relatively rare, affecting about 4 of 1000 people in the United States. Cluster headaches are more common among men. They typically begin between the ages of 20 and 40.

Drinking alcohol may trigger attacks.

Symptoms

An attack almost always starts suddenly. It may begin with a watery discharge from one nostril. Excruciating pain on the same side of the head follows and spreads around the eye. The pain peaks in intensity within minutes and usually lasts 30 minutes to 1 hour but may last 15 to 180 minutes. The pain often awakens people from sleep.

People with cluster headaches, unlike those with a migraine, cannot lie down. They frequently pace and sometimes bang their head on a wall.

After the attack, the eyelid on the same side as the headache may droop, and the pupil often constricts. The area below the eye may swell, and the eye may water. The face may be flushed. Nausea may accompany the headaches.

Attacks may occur several times a day, often at the same time of day or night. They usually occur regularly during a 1- to 3-month (or occasionally longer) period—called a cluster period—which is followed by a headache-free interval of several months, or even years, before attacks recur. Alcohol may trigger headaches during a cluster period, but not during the headache-free interval. Some people do not have a headache-free interval. They have chronic cluster headaches.

Diagnosis

  • A doctor's evaluation

  • Sometimes magnetic resonance imaging

Diagnosis of cluster headaches is based on the person’s description of the headache and the accompanying symptoms.

If the headaches have developed recently or if the pattern of symptoms has changed, magnetic resonance imaging (MRI) of the head or computed tomography (CT) may be done.

Treatment

  • Oxygen or a drug to stop headaches from starting or progressing

  • Drugs to prevent cluster headaches

Many people with cluster headaches need to take drugs to prevent recurrences.

The following may be used to stop (abort) a cluster headache as it is starting or to keep it from progressing:

  • Oxygen given by face mask

  • A triptan or dihydroergotamine given by injection (see Table: Drugs Used to Treat Migraines)

  • Zolmitriptan (a type of triptan) or a local anesthetic (such as lidocaine) taken by nasal spray

Because cluster headaches are so severe, frequent, and incapacitating, many people who have them are given drugs to prevent them:

  • Prednisone, a corticosteroid given by mouth

  • A local anesthetic plus a corticosteroid given by injection into the back of the head (a procedure called a nerve block)

  • Drugs used to prevent migraines (such as divalproex, topiramate, valproate, and verapamil)

  • Lithium

Prednisone or a nerve block may be used first because they take effect more quickly. Then one of the other drugs is used for long-term prevention. Injections of a local anesthetic plus a corticosteroid must be given in the doctor's office. The other treatments can be taken at home.

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • XYLOCAINE
  • LITHOBID
  • RAYOS
  • ZOMIG
  • CALAN
  • D.H.E. 45, MIGRANAL
  • TOPAMAX

* This is the Consumer Version. *